"Bundled Payments for Care Improvement is a voluntary model, where potential participants can select whether they want to join. But we're not going to stick to voluntary models," Azar said in a speech Thursday before the Patient-Centered Primary Care Collaborative Conference.

"BPCI Real experimentation with episodic bundles requires a willingness to try mandatory models. We know they are the most effective way to know whether these bundles can successfully save money and improve quality," Azar said.

The mandatory payment models would be a sharp departure for the Trump administration, which in the past has steered away from forcing providers into downside risk models.

Azar on Thursday said the HHS has "reexamined" last year's decision to reduce the size of the Comprehensive Care for Joint Replacement Model, and its decision to pull back on cardiac care episode payment models before they were even launched.

"We intend to revisit some of the episodic cardiac models that we pulled back, and are actively exploring new and improved episode-based models in other areas, including radiation oncology," he said.

"We're not going to stop there: We will use all avenues available to us—including mandatory and voluntary episode-based payment models," he said.

Azar's comments will likely irritate physicians who generally support voluntary alternative payment models, but who've warned that there's not enough evidence to show that at-risk models work.

American Society for Radiation Oncology CEO Lauran Thevenot said her association has "aggressively pursued" adoption of CMS's proposed radiation oncology APM, but she stopped short of endorsing mandatory participation.

"While ASTRO is enthusiastic about the prospects for a RO-APM, we have concerns about the possibility of launching a model that requires mandatory participation from all radiation oncology practices at the outset," Thevenot said.

"ASTRO believes it is important to acknowledge that any radiation oncology payment model will represent a significant departure from the status quo," Thevenot said. "Care must be taken to protect access to treatments for all radiation oncology patients and not disadvantage certain types of practices, particularly given the very high fixed costs of running a radiation oncology clinic."

"We want to advance models like these in a collaborative manner. That has been a key priority for this administration since day one," Azar said. "But there is nothing virtuous about maintaining outdated systems within Medicare fee-for-service—effectively a mandatory system for so long—when we know we could be exploring better alternatives."

"We need results, American patients need change, and when we need mandatory models to deliver it, mandatory models are going to see a comeback," he said.

Mandatory alternative payment models have never been popular with physicians. A Medical Group Management Association poll in March found that 72% of medical group practices oppose the idea.

"Despite support for APMs, a large majority of physician practices oppose government mandated participation, citing lack of evidence, diversity among medical practices, and the negative impact on practice innovation," Anders Gilberg, MGMA's senior vice president of government affairs said at the time.

Azar's reversal of Trump administration policy on mandatory payment models should not come as a complete surprise. Azar has always been more receptive to the idea than his predecessor Tom Price, MD.

During his confirmation hearing in January Azar told the Senate Finance Committeethat "we need to be able to test hypotheses."

"I want to be a collaborative in doing this. I want to be transparent and follow appropriate procedures. But if to test a hypothesis around changing our healthcare system it needs to be mandatory as opposed to voluntary to get adequate data, then so be it," Azar told the committee.

“Bundled Payments for Care Improvement is a voluntary model, where potential participants can select whether they want to join. But we're not going to stick to voluntary models.”

HHS Secretary Alex Azar

John Commins is a senior editor at HealthLeaders.

KEY TAKEAWAYS

Azar's comments signal a sharp policy reversal at HHS.

The secretary says it's time to aggressively pursue alternatives to FFS payment models.